Ottawa, the Land of Rules

I’ve been to Canada, but I’ve never been to Ottawa. I suppose, as the capital of Canada, it makes sense they’d be enamored with rules and rule-making. Regardless, it still seems they have a disproportionate burden of rules, for better or worse.

This latest publication describes the “Ottawa Chest Pain Cardiac Monitoring Rule”, which aims to diminish resource utilization in the setting of chest pain in the Emergency Department. These authors posit the majority of chest pain patients presenting to the ED are placed on cardiac monitoring in the interests of detecting a life-threatening malignant arrhythmia, despite such being a rare occurrence. Furthermore, the literature regarding alert fatigue demonstrates greater than 99% of monitor alarms are erroneous and typically ignored.

Using a 796 patients sample of chest pain patients receiving cardiac monitoring, these authors validate their previously described rule for avoiding cardiac monitoring: chest pain free and normal or non-specific ECG changes. In this sample, 284 patients met these criteria, and none of them suffered an arrhythmia requiring intervention.

While this represents 100% sensitivity for their rule, as a resource utilization intervention, there is obviously room for improvement. Of patients not meeting their rule, only 2.9% of this remainder suffered an arrhythmia – mostly just atrial fibrillation requiring pharmacologic rate or rhythm control. These criteria probably ought be considered just a minimum standard, and there is plenty of room for additional exclusion.

Anecdotally, not only do most of our chest pain patients in my practice not receive monitoring – many receive their entire work-up in the waiting room!

“Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring”

3 thoughts on “Ottawa, the Land of Rules”

  1. Managing your chest pains in a waiting room because the hospital is dysfunctional is neither evidence that it is safe, or IMHO anything that should even have the whiff of something to be proud of. Many things now happen in waiting rooms that shouldn’t due to overcrowding and dysfunctional systems, but we should always remind ourselves how substandard that is for patients, staff and probably system management. As always Stiell et al go about things the right way, you nibble backwards- and prove the obvious, predictable stuff first. If the rest of it is so self evident and easy as well, I shall look forward to the easy to do next study your unit is no doubt about to perform, excluding the other 75% from monitoring!

    1. Well stated! Foundational research is important, if only to simply describe the lay of the land.

      That said, it is clear this rule – with its two criteria – falls well short of a significant leap in resource conservation. From my standpoint, I have issues with their primary safety outcome. Development of atrial fibrillation while unmonitored is not necessarily an important patient-oriented adverse event. It is unfortunately the case that, as you say, in the real-world we do not have the luxury of optimal system management and need to extend our practice beyond the minimum safety described in the evidence. In our context, it remains an individual clinical judgement call after in-person evaluation and ECG.

      As far as the research goes, those of us in the community do not have the same access to research support resources as Stiell et al; an administrative data dump of our chest pain patients triaged to the lobby would not have the same reliability as their analysis – but it is on our list of operational data sets to evaluate as our ongoing monitoring of potentially risky processes.

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